“Men have always sensed that the more they forged and the more machines they built, the more they were forced to know, to love, and to serve these devices.” –Edmund Pellegrino, MD[1]
Among the numerous advances of technology in the practice of medicine, the electronic medical record (EMR) is unique, because it insinuates itself into a fundamental aspect of the patient-physician relationship: the clinical encounter. In an increasingly common scenario, there is a “third person” in the room with the patient and physician, represented by a screen and keyboard into which the physician enters and from which she retrieves information. The widespread adoption of the EMR introduces new ethical considerations into the practice of medicine, some of which are common to any extension of technique into medicine, and some of which are unique to the EMR.
One way of analyzing the EMR or any technology is to take a step back and examine the category of technique. This category is perhaps not one with which many of us are familiar. It is not equivalent to technology, with which it is easily confused, although what we commonly think of as technology—gizmos and gadgets such as dishwashers, smart phones, and MRI scanners—is a subset of technique. Lewis Mumford defined technique (he used the word technics) as “a translation into appropriate, practical forms of the theoretic truths, implicit or formulated, anticipated or discovered, of science.”[2]
Of course, people have always employed technique; but the contemporary situation, in which technique has taken over our environment, is unique in history. In his Technics and Civilization, Mumford recounts how, during the 17th and 18th centuries, the close link between scientific research and technological invention developed, radically altering the relations between technique and civilization. The amazing successes of science applied to invention led to the widespread acceptance of the notion that applying the principles of scientific research to all domains of life would therefore be a beneficial practice. Thus, those qualities that make scientific research successful—objectivity, reductionism, standardization, the reduction of all characteristics to quantitative measurement (and the corollary classification of anything that cannot be quantified as “subjective,” and therefore less valid)—were, and are being, firmly established and extended into all domains of human life. In short, technique is our environment.
The 20th-century French sociologist Jacques Ellul emphasized this all-encompassing aspect when he wrote that technique “does not mean machines, technology, or this or that procedure for attaining an end. In our technological society, technique is the totality of methods rationally arrived at and having absolute efficiency (for a given stage of development) in every field of human activity.”[3] Technique is about making everything rational, so that every human activity is analyzed and reshaped in such a way as to eliminate spontaneity or intuition. “Man’s traditional, spontaneous activities are now subjected to analysis in all their aspects—objects, modes, duration, quantities, results.”[4] Technique is also about “absolute efficiency.” In our technological society, efficiency is the “universally applicable criterion of social choice.”[5] Seeking the single most efficient means is the “main preoccupation of our time.”[6] Efficiency becomes the standard for all decisions, overriding any other competing standard, such as aesthetics or ethics. Certainly we see this at work today; one has only to defend a particular choice by saying, “This way is more efficient,” to get all heads in the room nodding in agreement.[7] Technique is not just our environment, but our mindset as well.
So technique is not about machines, per se, but the subjugating of all of human activity to the methods of the machine. And yet, the machine provides the best metaphor for technique, for as Ellul wrote, technique “transforms everything it touches into a machine.”[8] Now we may use the expression, “He’s a machine!” as a compliment, meaning that a person does something particularly well, tirelessly, and consistently. However, Ellul uses the word “machine” in a sense that is decidedly not complimentary. He understands that “machineization” or “technicization” is opposed to characteristically human modes of living, and thus leads to “dehumanization.” Or as Mumford expressed it, “the calculus of energies...takes precedence over the calculus of life.”[9]
A significant aspect of technique is that each new individual technique or technology carries within it an idea, an ideology.[10] Techniques are often portrayed as value-neutral: it is not the technique that carries moral content, rather, it is how we use it (or as is commonly claimed “Guns don’t kill people; people kill people.”). But each new technique changes, sometimes imperceptibly, our assumptions about the world and our function in it, and it does so based on qualities inherent in the technique itself. Thus each new technique carries within it the seed of an idea, and change of technique is therefore not merely additive but ecological.[11] Applying these concepts to healthcare, when one adds the EMR into medical practice, one does not have merely “medical practice + EMR”; one has a different medicine—a different idea about medicine, a different practice of medicine, a different concept of what makes up medical practice.
To provide evidence that introducing a technique into a field alters the meaning of that field, consider the following experience from my work as an attending physician in a Family Medicine residency program. When I am attending on the inpatient service, I still like to go on bedside rounds with the residents. My residents enjoy seeing patients as well (otherwise they would not have chosen Family Medicine as their specialty!), but, like all residents these days, they are required in the course of their work to spend hours in front of the EMR’s computer screen attending to what Abraham Verghese calls the “iPatient”[12]—many more hours, in fact, than they can spend in the presence of their patients. On one particular day I was rounding with my residents, and I could feel the tension rising in one of them as we went from room to room, taking our time to listen to patients and examine them. Finally she burst out, “Can we hurry up and get through with this so we can get back and do our work?” By “our work,” she meant “getting back to the computers in our resident room,” as opposed to “listening to and examining patients.” It is not difficult to see how the technique of the EMR is redefining just what the work of a doctor is, and that it is redefining it in technical terms. It is an ecological change, not merely an additive one.
Another salient aspect of technique is that in the technical system, we are compelled to use our techniques. Ellul used a few different terms to describe this aspect of technique: it is monistic, self-augmenting, and autonomous. Monism, as Ellul uses the term, means that a technique tends to be applied everywhere it can be applied, without regard to whether it is a “good” or “bad” use. Self-augmentation describes how technique “is being transformed and is progressing almost without decisive intervention by man.”[13] Humans catalyze rather than control the augmentation of technique. We are “so enthusiastic about technique, so assured of its superiority, so immersed in the technical milieu,”[14] that we simply assume that more technology is inherently good, and we automatically apply it everywhere it can be applied, whether or not the occasion demands it.[15] There are certainly occasions that demand technique, and medicine is rife with them: by technique medicine has achieved astonishing victories over many of mankind’s most terrible scourges. But technique takes on a very fertile life of its own, for which Ellul used the term autonomy. The development of technique inevitably creates technical problems, unforeseen consequences which can only be resolved by the elaboration of another technique, thus assuring technique’s increase.
So we gradually relinquish increasing domains of life to technique, seemingly unable or unwilling to put appropriate limits on it. As our freedom to choose anything outside of the technical system is diminished, we see all that we gain from technique; but we rarely if ever pause to consider what we lose. Technique, for all the good it offers, is a double-edged sword; to use a medical analogy, it has a very narrow therapeutic range. When unchecked, it is a force that naturally dehumanizes whatever it touches; applied indiscriminately, it acts to diminish the nature of medicine as a human profession, transforming it instead into a machine-like activity, driven by efficiency, and maladjusted to the human beings who practice it and whom it is meant to serve.
How might the concept of technique help us evaluate the use of EMRs in medical practice? The EMR has gained momentum since the 1960s when Lawrence L. Weed first introduced the concept.[16] In the 1970s, academic and research centers began to implement EMR-like systems in the inpatient setting. In the late 1980s, low-cost PCs became available and started to appear in physicians’ offices, used mostly for billing and coding. In 1996, the Veterans Health Administration mandated the use of EMRs in all of its facilities. In 1999, the Institute of Medicine (IOM) published its landmark report, “To Err is Human: Building a Safer Health System,” in which it stated that between 48,000 and 98,000 people in America die annually as a result of preventable medical errors. In 2001, the IOM followed up with a report entitled, “Crossing the Quality Chasm: A New Health System for the 21st Century.” Both reports promoted EMRs as a way to reduce medical errors, improve patient safety, and increase the quality of medical care.
In 2004, President Bush called for widespread adoption of EMRs by 2014. In 2009, the Health Information Technology for Economic and Clinical Health Act was passed, authorizing the use of $26 billion to promote the adoption of health information technology, including incentive payments to those who demonstrate “meaningful use” of an EMR system. In 2011, the IOM published the report, “Health IT and Patient Safety: Building Safer Systems for Better Care.” This report called for the establishment of an independent federal body to investigate patient deaths and other adverse events caused by EMRs and other health information technology. By 2013, 78% of office-based physicians were using some type of EMR.
This rapid adoption of the EMR is unremarkable on one hand, given the broader societal trends in the proliferation of digital technologies and rising interest in Big Data. Furthermore, the government directly incentivized the transition, and, beginning this year, entities that do not demonstrate “meaningful use” of an EMR will start facing financial penalties. On the other hand, however, it is quite remarkable; because in a medical field that has adopted the mantra of evidence-based medicine, which is the idea that medical treatment should be guided by the best statistical data derived from the study of populations, there is remarkably little evidence that EMRs either reduce medical errors, improve patient safety, or increase the quality of medical care—the very goals that the IOM reports averred would be achieved through EMRs.
So why the push from the government to adopt EMRs? And why the headlong rush of medical care providers to adopt them? One response may be that EMRs will contribute greater pools of statistical data sets, but the value of such data remains to be seen. Absent actual evidence that it makes a positive difference, does the answer lie in the nature of technique? The computer can be used in medicine; therefore it must be (Ellul’s monism). The computer is an advanced technology; therefore it must advance the practice of medicine, make it better, because we believe that more technology, particularly the latest technology, is always better. The computer promises greater efficiency (even if it has yet to deliver on that promise); therefore, it is the obvious choice.
But the EMR, like all techniques, carries within it an idea, or multiple ideas. One of those ideas can be expressed by a variation on the old maxim, “To a man with a hammer, everything looks like a nail”; that is, “To a person with a computer, everything looks like data.” Medicine is rapidly embracing the idea that it should be data-driven; it is supposed that the more data we can amass about patients and diseases and treatments, the better able we will be to treat patients’ diseases. Computers are absolutely necessary for the recording and manipulating of that data. This will almost certainly be a positive thing for medical practice in many ways. We will have gained much. But will we lose anything? This is the question that is rarely, if ever, asked. What, if anything, do we lose by adoption of the EMR?
For a very long time, the basic economy of medicine has been a relationship between two people: one person with a problem, and another person with some skills and a professional duty to act in the first person’s best interest. That relationship necessarily involves careful listening and observation—full attention—by the professional in order to diagnose and treat correctly. In many cases the relationship itself has been efficacious for healing, not only in times past when effective treatments were rare, but even today, when a vast armamentarium of powerful treatments and medicines lies at our fingertips. The EMR, as currently implemented, introduces a rival for the physician’s attention directly into the exam room. The EMR, as currently implemented in most places, requires a physician to spend large portions of the patient visit focusing attention on data entry, attending to the screen instead of the patient, attending to the needs of the computer for data in preference to the needs of the person in front of him for his full presence.
What is potentially lost by the adoption of the EMR? The primacy of the physician-patient relationship in medical practice. The careful observation of the patient. Presence. Things basic to relationship, like eye contact and body language that says, “For this period of time, you are most important to me.” The common courtesy of giving full attention; with our ubiquitous computers, we are at risk of “legitimizing rudeness.”[17] But EMR vendors and proponents will never mention these potential drawbacks; we hear only of the great things that we will gain by adopting the EMR.
Some of the effects of introducing the EMR into the exam room have been studied and documented. These studies have shown that doctors find EMR a limitation to their practice and, ultimately, that the needs of the machine take precedence over the importance of the human relationship. On average, physician visits take longer when an EMR is used in the exam room; however, this lengthening is not attributed to increased time in conversation, but to time spent logging data on the computer or tablet. The data entry activities are noted to contribute to inhibition of physician engagement in psychosocial question asking, eye-to-eye contact, focusing on patients, and emotional responsiveness, although there is the positive effect of increased exchange about biomedical and therapeutic matters. The physician using the EMR tends to efficiently structure the patient visit around data-gathering rather than around patients’ own narratives, methodically pointing-and-clicking their way through the patient interview.[18]
Attitudes of physicians towards EMRs were examined in a 2013 mixed-methods study of professional satisfaction sponsored by the American Medical Association (AMA). The study notes that “the most novel and important findings concerned how physicians’ perceptions of quality of care and use of electronic health records affected professional satisfaction.”[19] Physicians noted positive aspects of EMR use: for the most part, they approve of the concept of the EMR. They appreciate the ability for remote access and the ability to communicate via e-mail with other providers and patients. They appreciate its potential to improve care quality and patient satisfaction as user interfaces and health information exchange improve.
On the negative side, physicians note the poor usability of EMRs and time-consuming data-entry, finding that it interferes with face-to-face patient care, and leads to less-fulfilling work content. They are frustrated by the inability to exchange information between EMRs and the degradation of clinical documentation. They feel the burden of information overload, and that they are doing clerical work, rather than working “at the top of their license.” Interestingly, having more EMR functions, such as reminders, alerts, and messaging capabilities, was associated with lower professional satisfaction. Apparently, where the EMR can enhance communication, physicians are in favor of it. Where the EMR is a hindrance to communication and displaces the patient-physician relationship in favor of mechanical exercises, physicians sense the degradation of their profession.
As with any technique, the EMR brings with it a host of unintended consequences, some of which are detailed above. Among others that have been documented include the introduction of new work for physicians; things that were once done by other people, such as typing, coding, and billing, are now done by physicians, which necessarily takes time from other activities, such as being with patients.[20] There is the never-ending presence of new demands. The forms for paper charts remained unchanged for decades without significant upgrades. EMRs, however, are constantly being tinkered with and “improved,” leading to the need for continuous upgrades to hardware and software, and the need for continuous physician training to become familiar with new or changed system features. Whereas the EMR is supposed to facilitate communication between different team members, another unintended consequence has been the introduction of new types of communication errors. For instance, without the EMR, one might have to call or otherwise directly contact another person participating in the care of a particular patient; the EMR, however, can create “the illusion of communication,” that is, the false belief that if I enter information into the chart, the right person will automatically see it.
Apart from the particular issues raised by the EMR’s extension of technique into the physician-patient relationship, there are other ethically important consequences of EMR adoption. One has to do with the accuracy of the information in the EMR, and relates to the widespread usage of templated notes and “copy-and-paste” functionality. Much of the documentation in EMRs is in the form of standardized templates, in which the physician points-and-clicks and/or the computer automatically fills in information from the patient’s database. Many times documentation is copied-and-pasted from previous entries,[21] without any way to tell which information in the note was actually obtained from the patient and what was blithely copied from a previous note or automatically “blown in” by the computer. This can generate massive notes, loaded with extraneous data that is never actually read or reviewed, because nobody actually has the time to review it. (It can also lead to absurdities that I have personally observed, such as a detailed description of male genitalia documented on a female patient!) In this way, a single error in documentation propagates and is preserved in subsequent documentation—documentation that is used not only for patient care, potentially endangering a single patient, but also for research, in which the error potentially affects the treatment of whole populations of patients. Here the concern is not the collection of data as such, but the accuracy of the data itself.
Templated EMRs also undermine patient individuality and life narrative. Within the confines of an EMR’s templated documentation, patient particulars can and often do get lost, and in the chart all patients start to look the same.[22]
Another serious and growing concern with the EMR is the frequency of privacy breaches. Stolen medical records, containing details such as social security numbers and credit card information, sell at a high price on the black market. According to a report published in May, the health records of at least 88.4 million people were breached last year (although security experts say there were probably far more that have gone undetected), and the numbers are already higher for 2015.[23] Cyber-attacks are costing the U.S. healthcare system $6 billion annually; more worrisome than the money, however, is the breach of the trust and privacy which have been enshrined in medical practice since Hippocrates.
Another potential source of privacy breaches comes from those with legitimate access to the EMR. One of the drawbacks of current EMR systems is that different EMRs often cannot communicate with each other. If a patient is seen in the emergency department of a hospital outside of my system, I have no access to the record of that visit. This has led to the effort to create Health Information Exchanges (HIEs), central repositories for the sharing of data between systems. However, the access to such data will be extremely difficult to control. In my own hospital system, access to the EMR is automatically monitored to make sure that people are not inappropriately accessing the charts of family members or celebrity patients. However, if data from multiple systems is collected in a central HIE, there is nothing to stop “a meddlesome pharmacist in Alaska” who “looks up the urine toxicology on his daughter’s fiancé in Florida, to check if the fellow has a cocaine habit.”[24]
Another privacy issue involves EMR vendors’ use of patient data. Several EHR vendors (among them Cerner, GE, and Allscripts) sell de-identified copies of patient databases in their systems to pharmaceutical companies, medical device makers, and health services researchers. It has proven easy, using the Internet, to “re-identify” the data.[25]
The story of the EMR is one of good intentions and unintended consequences. Some of the negative consequences are amenable to technical solutions. The integrity of documentation can be protected by removing the functionalities that automatically write notes in the chart; the privacy and safety of patient data can and must be protected by the elaboration of better computer security; and the selling of de-identified patient data must be discontinued. It is untenable that patients must risk privacy invasion and identity theft every time they see their physician.
However, some of the negative consequences of the EMR are not so amenable to technical innovations, since they arise from the essential nature of the EMR as part of the system of technique. The EMR, by its presence in the midst of the patient-physician relationship, brings the most intimate and personal aspect of the practice of medicine into the harsh glare of the system of technique. Its intrinsic tendency is to introduce the “spirit of machineness” into a human activity or relationship characterized by intuition, empathy, and spontaneity. The move toward using scribes, people in the exam room who attend to the computer so that the physician can attend to the patient, is one way physicians are countering the negative effects of the EMR on this relationship. Even so, much of the work of EMRs appears to be characterized by humans adapting to the machine. Instead of the physician laboring to conform to the requirements of the EMR, programmers must labor to adapt the technology to the needs of the humans using it.
In the education of medical students and residents, the centrality of the patient-physician relationship must be continuously reasserted. Students from a generation immersed in computer technology and virtual worlds must repeatedly be reminded and shown by example that important clinical information is lost when physicians fail to observe the patient in front of them. Instead, they must learn that the most important information is not found in computer databases but in the eyes and faces and bodies and stories of their actual patients.[26]
[1] Edmund Pellegrino, Humanism and the Physician (Knoxville: University of Tennessee Press, 1979), 10.
[2] Lewis Mumford, Technics and Civilization (Chicago: University of Chicago Press, 2010), 52.
[3] Jacques Ellul, The Technological Society (New York: Vintage, 1964), xxv (Emphasis in original).
[4] Ibid., 395.
[5] Langdon Winner, “Foreward,” in Mumford, Technics and Civilization, xii.
[6] Ellul, The Technological Society, 21.
[7] This facet of technique raises the question of human freedom in making choices. Efficiency is determined by mathematical calculation. If the sole standard in the technological society for making choices is efficiency, then when we “choose” between one course of action and another, all we are really doing is measuring which option is most efficient and taking the inevitable course laid out for us by calculation. We become tabulators rather than choosers. Ellul described this as the “automatism of technical choice.”
[8] Ellul, The Technological Society, 4.
[9] Mumford, Technics and Civilization, 249.
[10] Neil Postman, Technopoly: The Surrender of Culture to Technology (New York: Vintage, 1992), 13.
[11] Ibid.
[12] Abraham Verghese, “Culture Shock: Patient as Icon, Icon as Patient,” New England Journal of Medicine 359, no. 26 (2008): 2748–2751.
[13] Ellul, The Technological Society, 85.
[14] Ibid.
[15] Mumford, Technics and Civilization, 240.
[16] Lawrence Weed, “Medical Records that Guide and Teach,” New England Journal of Medicine 276, no. 11 (1968): 593–600.
[17] Catherine Wellbury, “Our Ubiquitous Technology,” JAMA 307, no. 12 (2012): 1263–1264.
[18] Roter Margalit et al., “Electronic Medical Record Use and Physician-Patient Communication: An Observational Study of Israeli Primary Care Encounters,” Patient Education and Counseling 61, no. 1 (2006): 134–141; William Adams, Adriana Mann, and Howard Bauchner, “Use of an Electronic Medical Record Improves the Quality of Urban Pediatric Primary Care,” Pediatrics 111, no. 3 (2003): 626–632; William Ventres, Sarah Kooienga, and Ryan Marlin, “EHRs in the Exam Room: Tips on Patient-Centered Care,” Family Practice Management 13, no. 3 (2006): 45–47; Gregory Makoul, Raymond H. Curry, and Paul C. Tang, “The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters,” Journal of the American Medical Informatics Association 8, no. 6 (2001): 610–615; William Ventres et al., “Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis,” Annals of Family Medicine 4, no. 2 (2006): 124–131.
[19] Mark Friedberg et al., Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. (Washington, D.C.: RAND Corporation, 2013), 33–47.
[20] See, for example, Joan S. Ash et al., “The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry.” Journal of the American Medical Informatics Association 14, no. 4 (2007): 415–423.
[21] For a humorous example, see Robert Hirschtick, “Copy-and-Paste,” JAMA 295, no. 20 (2006): 2335–2336.
[22] Ventres et al., “Physicians, Patients, and the Electronic Health Record,” 129.
[23] Shannon Pettypiece, “Rising Cyber Attacks Costing Health System $6 Billion Annually,” Washington Post, May 7, 2015, http://washpost.bloomberg.com/Story?docId=1376-NNY4TE6JIJVE01-0JG7O26B2FS76S86ARFIPFFAJ6.
[24] Jacob Appel, “Why Shared Medical Database Is Wrong Prescription,” Orlando Sentinel, December 30, 2008, http://articles.orlandosentinel.com/2008-12-30/news/OPappel30_1_medical-records-medical-systemelectronic-medical.
[25] Dean F. Sittig and Hardeep Singh. “Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use,” Pediatrics 127, no. 4 (2011): e1042–e1047.
[26] Pamela Hartzband and Jerome Groopman, “Off the Record—Avoiding the Pitfalls of Going Electronic,” New England Journal of Medicine 358, no. 16 (2008): 1657.
Joseph P. Gibes, "Electronic Medical Records: A Story of Technique and Medicine,” Dignitas 22, no. 2 (2015): 8–13.
